Cancer Mortality Data Trends, California 2000-2010

At a Glance

In California and nationally, cancer (malignant neoplasms) was the second leading cause of death for each year from 2000 through 2010.

Cancers from lung, colon, breast, pancreas, and prostate accounted for more than 50 percent of cancer deaths in California.

Cancer deaths increased with age. Approximately 70 percent of cancer deaths occurred among those aged 65 and older. Those aged 65 to 84 accounted for 53.5 percent of deaths, and those aged 85 and older represented 15.7 percent of cancer deaths.

There was a statistically significant downward trend in California’s mortality rate for cancer. California’s age-adjusted cancer death rate dropped from 182.2 in 2000 to 156.6 in 2010, a 14.1 percent decrease.

Consistently higher age-adjusted cancer death rates were seen in males than females. However, both males and females exhibited statistically significant decreasing trends.

Significant decreasing cancer trends were observed in Asians, Blacks, Hispanics and Whites. Two or More Races category experienced a significant increase, possibly due to improved race reporting on the death certificate.

Statistically significant decreasing trends were seen in 32 of California’s 58 counties. Humboldt County demonstrated the greatest numerical and percentage decreases when comparing 2000 to 2010 data.

For the study period, the lowest average age-adjusted cancer death rate occurred in Lassen County. The highest average age-adjusted cancer death rate occurred in Mariposa County.

This report was authored by Alicia Van Hoy, MA, Research Program Specialist. Please contact DAReports@cdph.ca.gov for further information.

Background

From 2000 to 2010, cancer (malignant neoplasms) has been the second leading cause of death in California and the United States, only to be exceeded by heart disease.1,2 In California, lung, colon, breast, pancreas, and prostate cancers accounted for more than 50 percent of cancer deaths.

There are more than 100 different types of cancers.3 All cancers begin as out-of-control abnormal cell growths, which left untreated may result in serious illness and/or death.4 Half of all men and one-third of all women in the United States will develop some form of cancer during their lifetime.4 Cancer can be diagnosed at any age, but those who are 65 and older account for over 70 percent of cancer deaths.5

Cancer can be caused by both external factors (tobacco, chemicals, radiation, and infectious organisms) and internal factors (inherited mutations, hormones, immune conditions, and mutations that occur from metabolism).4 Scientific evidence suggests that many types of cancer can be prevented by not using tobacco and alcohol products, being physically active, eating a healthy diet, maintaining an ideal body weight, and limiting exposure in the sun. Furthermore, regular screening examinations can result in the prevention of certain cancers through the early discovery and removal of precancerous lesions. Available treatments for cancer include surgery, radiation, chemotherapy, hormone therapy, biological therapy, and targeted therapy.4

Cancer prevention and early detection are vital to reduce suffering of patients and family members, deaths, and financial costs related to cancer.6 In 2010, the overall estimated cost of cancer was $263.8 billion, which represented $102.8 billion for direct medical health expenditures, $140.1 billion in lost productivity due to premature death, and $20.9 billion in lost productivity due to illness.4

Due to the prevalence of cancer deaths in this country, the U.S. Department of Health and Human Services (HHS) has established a number of Healthy People 2020 objectives that pertain to specific cancer types. HHS has established Healthy People 2020 Objective C-1, to reduce the overall cancer age-adjusted death rate of no more than 160.6 per 100,000 population.7 The definition of cancer used for the Healthy People Objective C-1 and the report’s content was based on the International Classification of Diseases, Tenth Revision (ICD-10) codes C00-C97.

This report examines cancer mortality trends for California’s resident population from 2000 through 2010 and presented data in five major sections. The first section discusses cancer mortality for the total California resident population. The second section analyzes male and female populations separately. The third section describes differences in cancer mortality by race/ethnicity groups. The fourth section discusses sex differences within race/ethnicity groups. The final section reviews trends in cancer mortality by county of residence and includes trend charts for each county. Combined with information on cancer prevention, early detection, and treatment, the information is useful for program planning and policy development to reduce the burden of cancer.

California Total Population

Nationally and in California, cancer (malignant neoplasms) has been the second leading cause of death from 2000 through 2009, only to be exceeded by heart disease.1, 2 United States data was available through 2009.

The age-adjusted death rate for cancer was lower in California than the United States for each year during the study period. The chart below displays California’s age-adjusted death rates from 2000 through 2010, compared with the available United States rates.

California’s age-adjusted cancer death rate significantly declined from 2000 to 2010. In 2010, the age-adjusted death rate for cancer per 100,000 California residents was 156.6, representing a decrease of 14.1 percent from a rate of 182.2 in 2000. Beginning in 2008 to the current study period, California attained the Health People Objective 2020 in reducing the age-adjusted death rate for cancer of no more than 160.6. Annual age-adjusted death rates are shown in Table 3 (PDF).

Age Distribution of Cancer Deaths

The number of deaths in California from 2000 to 2010 was 2,571,224. Cancer accounted for 23.3 percent of all deaths in California (N= 598,786).

The average age of death due to cancer was 70.5 years with a standard deviation of 14.4 years. Approximately 70 percent of all cancer deaths occurred among those aged 65 and older. Deaths due to cancer for those aged 65 to 84, accounted for 53.5 percent of deaths and those aged 85 and older represented 15.7 percent of cancer deaths. The chart below shows the age distribution of cancer deaths for all California residents.

Age-Specific Rates

The risk of dying from cancer increases with age. The minimum and maximum annual age specific death rates per 100,000 population for 2000 through 2010 for age groups that had reliable rates during each study year were as follows:

Age-specific death rates showed significantly downward trends for most age groups — 1-4, 35-44, 45-54, 55-64, 65-74 and 75-84. Age-specific death rates during the study period remained stable for age groups 5-14, 15-24, 25-34 and 85 and older. Annual age-specific cancer death rates for the California population are displayed in Table 2a (PDF).

Crude Death Rates

During the study period, the actual risk of dying (or crude death rate) from cancer ranged from a high of 155.9 to a low of 148.1 per 100,000 population. Annual cancer crude death rates for the California population are displayed in Table 2a (PDF) under the “All Ages” column.

See the Technical Notes for information about rate calculation and trend analysis.

Counts

The average number of cancer deaths per year was 54,435 or approximately 150 deaths per day due to cancer in California. The number of deaths increased every year relative to 2000. There were slight fluctuations in number of deaths comparing year-to-year deaths. The largest amount of cancer deaths occurred in 2010 (N=56,124).

For additional information regarding the number of events, please see Technical Notes.

Male and Female Populations

Cancer (malignant neoplasms) was California’s second leading cause of death for males and females during all study years in this report.

Overall, the age-adjusted cancer death rate was lower for females than males throughout the study period. Both males and females experienced statistically significant rate decreases. For males, the age-adjusted cancer death rate fell from 218.6 in 2000 to 185.8 in 2010, a 15.0 percent decrease. The female rate dropped from 158.8 in 2000 to 136.4 in 2010, a 14.1 percent decrease. Annual cancer age-adjusted death rates are shown in Table 3 (PDF).

Age Distribution of Cancer Deaths by Sex

Of California’s 598,786 total cancer deaths from 2000 through 2010, the proportion was about half between males and females (304,915 deaths in males; 293,871 deaths in females).

The average age of death caused by cancer for males and females closely reflect each other. The male average age of death for the time period was 70.4 years with a standard deviation of 14.1 years. The female average age of death was 70.7 years with a standard deviation of 14.7 years.

Age-Specific Rates

The risk of dying from cancer increases with age for both sexes. Age-specific cancer death rates for both males and females were higher in older age groups. Both sexes under 34 closely reflect each other’s age-specific death rates. Females in age groups 35-44 and 45-54 generally had higher age-specific cancer death rates than males in the same age range. Males in age groups 55-64, 65-74, 75-84, and 85 and older had higher age-specific death rates than females in the same age range. Annual age-specific cancer death rates are displayed in Table 2b (PDF) for males and Table 2c (PDF) for females.

Crude Death Rates

During the study period, the actual risk of dying (or crude death rate) from cancer ranged from 151.7 to 158.7 deaths per 100,000 population for males. The female rate ranged from 145.5 to 153.7. Annual rates are displayed in Table 2b (PDF) for males and Table 2c (PDF) for females under the “All Ages” column.

See the Technical Notes for information about rate calculation and trend analysis.

Race/Ethnicity Group Differences

Leading Causes of Death

In the past eleven years, heart disease remains the leading cause of death in California. However, while the number of deaths due to heart disease continues to gradually decline each year from year-to-year, the number of cancer deaths slightly increase relative to the year 2000.

Leading Causes of Death by Race/Ethnicity

Heart disease and cancers deaths alternated as the number one leading cause of death based on race/ethnicity. Cancer was the second leading cause of death for every race/ethnicity in all years from 2000 through 2010 with the following exceptions:

• For American Indians, cancer replaced heart diseases as leading cause of death in 2010. • For Asians, cancer was the leading cause of death, except in 2002 when heart disease was the leading cause of death.• For Hispanics, beginning in year 2007 onward cancer deaths became the leading cause.• For Two or More Races, there has been slight fluctuation between cancer and heart disease as leading cause of death. Cancer became the leading cause of death in 2006, 2007, 2009 and 2010. In 2008, heart disease ranked one.

See the Technical Notes for information about leading causes of death and rankings.

Age-Adjusted Rates

The highest age-adjusted cancer mortality rates by race/ethnicity occurred in Blacks for each year of study.

Significant decreasing age-adjusted cancer mortality rates were observed in Asians, Blacks, Hispanics and Whites. Two or More Races experienced a significant increase, possibly due to improved race reporting on the death certificate.

The percent changes for age-adjusted rates between 2000 and 2010 varied among race/ethnicity :

• The age-adjusted death rate for Blacks decreased by 14.2 percent.• The age-adjusted death rate for Pacific Islanders decreased by 4.5 percent.• The age-adjusted death rate for Whites decreased by 12.8 percent.• The age-adjusted death rate for Hispanics decreased by 6.9 percent.• The age-adjusted death rate for American Indians decreased by 18.0 percent.• The age-adjusted death rate for Asians decreased by 10.8 percent.• The age-adjusted death rate for Two or More Races increased by 321.3 percent.

Age Distribution of Cancer Deaths by Race/Ethnicity

The average age of death due to cancer during the study period differed between race/ethnicity. Pacific Islanders had the lowest average age of 61.6 years and Whites had the highest average of 72.2 years. This means on the average Pacific Islanders died more than 10 years earlier from cancers when compared to Whites. The average age of death from cancer between 2000 and 2010 was:

• 61.6 years for Pacific Islanders (N=1,601)• 64.2 years Two or More Races (N= 2,466)• 65.0 years Hispanics (N=79,961)• 67.1 years for American Indians (N=2,028)• 67.2 years for Blacks (N=44,534)• 68.8 years for Asians (N=50,661)• 72.2 years for Whites (N=417,535)

While the majority of cancer deaths occurred to people over age 65, the distribution varied considerably among those people under the age of 65 based on race/ethnicity. Specifically, the proportion of cancer deaths before age 65 reflected:

• More than 50 percent among Pacific Islanders.• Between 40 and 49 percent for Blacks, Two or More Races, and Hispanics.• Between 30 and 39 percent for American Indians and Asians.• Less than 30 percent among Whites.

The chart below shows the age distribution of cancer deaths by race/ethnicity.

Age-Specific Rates

Age-specific death rates for all race/ethnicity were generally higher in older age groups. Annual age-specific cancer death rates are displayed in Table 2a (PDF).

Crude Death Rates

During the study period, the actual risk of dying per 100,000 population, or crude death rate, for race/ethnicity ranged as follows:

• American Indian, 94.4 to 118.7• Asian, 98.3 to 113.0 • Black, 176.7 to 191.7• Hispanic, 52.1 to 61.5• Pacific Islander, 100.6 to 131.1• Two or More Races, 11.1 to 45.4• White, 237.0 to 250.0

Annual cancer crude death rates by race/ethnicity are displayed in Table 2a (PDF) under the “All Ages” column.

See the Technical Notes for information about rate calculation and trend analysis.

Sex Differences Within Race/Ethnicity

Leading Causes of Death by Sex and Race\Ethnicity

During the years studied, there were fluctuations between cancer and heart disease for the top leading cause of death by sex and race/ethnicity.

• Cancer was the second leading cause of death for both sexes within Whites and Blacks.• For American Indian males, cancer was the second leading cause of death. For American Indian females, year-to-year fluctuation between heart disease and cancer as leading causes of death. • For Pacific Islander males, cancer was the second leading cause of death. Pacific Islander females alternated leading causes of death between cancer and heart disease.• For Asian males, starting in 2004 to current study period cancer deaths became the leading cause of death. Cancer was the leading causes of death for Asian females throughout the period. • For Two or More Races males, cancer deaths were the leading cause of death only in 2007. There were slight fluctuations between years from heart disease to cancer deaths as leading cause of death for Two or More Races females. • For Hispanic males, cancer became the leading cause of death in 2010. Cancer deaths became the leading cause of death in 2006 through current study year for Hispanic females.

See the Technical Notes for information about leading causes of death and rankings.

Age-Adjusted Rates

Age-adjusted cancer death rates were generally higher for males than females within the same race/ethnicity. Black males and Pacific Islander females had the highest age-adjusted mortality rates. Two or More Races females had the lowest age-adjusted cancer death rates over the period.

Both sexes within Whites and Blacks, American Indian males, Asian males, and Hispanic females demonstrated statistically significant downward trends during the study period. Males and females of Two or More Races showed a statistically significant increase through the period.

The chart below displays age-adjusted cancer death rates by sex and race/ethnicity for the years 2000 through 2010. Annual age-adjusted cancer death rates by sex and race/ethnicity are shown in Table 3 (PDF).

Age Distribution of Cancer Deaths by Sex and Race/Ethnicity

There were slight variations between the average age of death between males and females based on sex and race/ethnicity. Pacific Islander females had the lowest average age of cancer deaths and died an average of more than 12 years earlier than White females, the longest surviving group. The average age of cancer deaths by sex and race/ethnicity for 2000 through 2010 were as follows:

The percentage of deaths that occurred to people under age 65 varied by sex and race/ethnicity, and some groups experienced more deaths at younger ages than other groups. Specifically, the proportion of cancer deaths before age 65 was:

• More than 50 percent among Pacific Islander males and females.• Between 40 and 49 percent among Hispanic males and females, males and females of Two or More Races, and Black females.• Between 30 and 39 percent among Asian males and females, and American Indian females.• Less than 30 percent among White males and females.

The charts below show the age distribution of cancer deaths by sex and race/ethnicity.

Age-Specific Rates

The risk of dying from cancer increases with age. Age-specific death rates for all race/ethnicity grouped by sex were generally higher in older age groups. Annual age specific cancer death rates by sex and race/ethnicity are displayed in Table 2b (PDF) for males and Table 2c (PDF) for females.

Crude Death Rates

Annual cancer crude death rates by sex and race/ethnicity are also presented in Table 2b (PDF) for males and Table 2c (PDF) for females under the “All Ages” column.

See the Technical Notes for information about rate calculation and trend analysis.

County of Residence Populations

Fifty-four of California’s 58 counties had reliable age-adjusted cancer death rates every year from 2000 through 2010. Fifty-one counties had age-adjusted rates that were lower in 2010 than 2000, and three counties demonstrated higher rates in 2010 than 2000. Mariposa County had the highest age-adjusted death rate, and Lassen County had the lowest rate during the eleven-year period.

Refer to Table 4 (PDF), Table 5 (PDF), and Table 6 (PDF) for detailed counts of deaths, age-adjusted rates, and 95 percent confidence intervals by county of residence. Trend charts showing age-adjusted cancer death rates by county are accessible through the links provided below.

Out of 54 counties, 32 counties showed a statistically significant downward trend from 2000 to 2010. The largest numerical and percentage decreases occurred in Humboldt County, which showed a decrease of 25.3 percent from 2000 to 2010.

Four counties had rates that were unreliable or no events during one or more of the years studied. Graphs are provided for these counties, but no trend analysis was conducted. This information should be interpreted with caution.

See the Technical Notes for information about rate calculation and trend analysis. A map of California is located here.

Technical Notes

Number of Events – The number of events provides a description of how a disease affects a population, but it is not useful for examining trends or comparison across groups because the number of events largely depends on population size.8

Crude Rates, Age-Specific Rates, and Age-Adjusted Rates – The crude death rate (number of deaths per population size) is a widely used mortality measure.8 This rate represents the average chance of dying during a specified period for persons in the entire population. However, crude death rates are influenced by the age distribution of the population. As such, crude death rate comparisons over time or between groups may be misleading if the populations being compared differ in age composition.

The age specific death rate is defined as the number of deaths occurring in a specified age group divided by the population for the specified age group, usually expressed per 100,000 population. Age-specific death rates allow one to compare mortality risks of a particular age group over time or between age groups at a particular point in time. Although effective in eliminating the effect of differences in age composition, age-specific comparisons can be cumbersome, because they require a relatively large number of comparisons, one for each age group.9

To control for the effect of age on death rates and provide a single measure, age-adjusted death rates are used.8 Age-adjusted rates are computed by separating deaths into their respective age groups based on the age of the decedent, and computing age-specific rates. These age-specific rates are then weighted according to the 2000 U.S. Standard Population, and are summed to produce the age-adjusted rate. Age-adjusted death rates are highly effective for making comparisons among population groups and among geographical areas because they remove the effects of dissimilar age distributions.

Three important caveats apply when using age-adjusted rates. First, the age-adjusted death rate does not reflect the mortality risk of a “real” population. The actual risk of mortality is represented by the crude death rate. The numerical value of an age-adjusted death rate depends on the standard used and, as a result, is not meaningful by itself. Age-adjusted death rates are appropriate only when comparing groups or examining trends across multiple time periods. A comparison of age-adjusted death rates among groups or periods over time will reflect differences in the average risk of mortality.

Second, age adjusting may mask important information if the age-specific rates between comparison groups do not have a consistent relationship. As an example, Anderson and Rosenberg (1998)8 demonstrate that the trend in the age-adjusted death rate for cancer does not reflect the complexities in the underlying age-specific rates. As averages, age-adjusted rates, like other averages, may be misleading, especially when age-specific rates reflect divergent trends over time. However, usually age-specific rates move roughly in parallel. Thus, age-adjusted death rates are a widely accepted and useful convention for analyzing trends.

Finally, because age-adjusted death rates are averages, they represent merely the beginning of an analytical strategy that should proceed to age-specific analyses, and then to an examination of additional sociodemographic, temporal, and geographic variables.

Data Sources – Numerator data are taken from California Department of Public Health death records, and denominator population data are obtained from the Department of Finance 2012 “Race/Hispanics Population with Age and Gender Detail, 2000–2010. Sacramento, California, September 2012”. Due to the revised population estimates, rates may differ from previously published reports. The 2000 U.S. Standard Population was used for calculating age-adjustments in accordance with statistical policy implemented by NCHS.8 Age-adjusted death rates are not comparable when rates are calculated with different population standards, e.g., the 1940 U.S. Standard Population.

Variability of Rates – Rates are sensitive to size variations in both the numerator (the number of vital events that occurred) and the denominator (the estimated population at risk). For example, in small counties a numerator variation of only a few cases might cause a relatively large shift in a rate, while in a large county could cause no difference in the rate. Likewise, a minor revision in a small county population estimate may cause a relatively major change in a county’s vital event rate. Therefore, caution needs to be exercised when analyzing small numbers, including the rates derived from them.

Rates that are calculated from fewer than 20 deaths are considered unreliable (Tables 2a-2c). These rates are not shown, and are indicated with an asterisk (*). Unreliable age-adjusted rates by race/ethnicity and sex (Table 3) and county of residence (Table 5), are displayed with an asterisk (*) and are provided only as a point of information for further investigation. Rates based on no events are denoted with a dash (-).

Sampling Error and Vital Statistics – Vital events are essentially a complete count, because more than 99 percent of all vital events are registered. Although these numbers are not subject to sampling error, they may be affected by nonsampling errors in the registration process.

The number of vital events is subject to random variation and a probable range of values can be estimated from the actual figures, according to certain statistical assumptions. This is because the number of vital events that actually occurred can be thought of as one outcome in a large series of possible results that could have occurred under the same (or similar) circumstances.

A 95 percent confidence interval is the range of values for a measurement that would be expected in 95 out of 100 cases. The confidence intervals are the highest and lowest values of the range. Confidence intervals tell you how much a measurement could vary under the same (or similar) circumstances.

Confidence Intervals Based on 100 Deaths or More – When there were 100 deaths or more, a normal approximation was used to calculate confidence intervals.

Confidence Intervals Based on Fewer than 100 Deaths – When there were fewer than 100 deaths, a gamma distribution was used to calculate confidence intervals.

Detailed procedures and examples for each type of calculation are given in Technical Notes of Deaths: Final Data for 2009; National Vital Statistics Reports; National Center for Health Statistics, 2011.10

Cause of Death – One of the most important uses for vital statistics data is the study of trends by cause of death. Vital statistics trend research yields valuable information about population health status, emerging public health problems, and at-risk populations, and can be used to develop strategies and allocate resources to improve public health.

Cause-of-death statistics are derived from the medical information reported on the death certificate by the certifying physician or coroner. The medical portion of the death certificate has fields for up to four causes of death (immediate, two intervening, and underlying) plus additional fields for recording contributing causes of death. Up to 20 causes can be entered onto a single death certificate. The cause-of-death field selected for coding and tabulation in this report is the "underlying cause of death." This is generally defined as the disease, injury, or complication that initiated the morbid events sequence leading directly to death.

Leading Causes of Death – This report presents death by leading cause of death in California by sex and race/ethnicity. The leading cause-of-death are ranked according to the frequency of deaths within groups. Because the rank order of any particular cause of death will depend on the list of causes from which selection is made and on the rules applied in making the selection, a clearly defined, uniform method for ranking causes of death is vital to maintain consistency in the reporting of leading causes by federal and state agencies.11 To maintain consistency and to determine rankable causes of death, the ‘‘List of 113 Selected Causes of Death and Enterocolitis due to Clostridium difficile’’ was used to select 50 rankable causes (denoted by #) from which the leading causes. The rankable causes must be mutually exclusive.

Cause-of-death ranking is a popular method of presenting mortality statistics and is a useful tool for illustrating the relative burden of cause-specific mortality, but it must be used cautiously with a clear understanding of the limitations underlying the method. Rankings do not illustrate cause-specific mortality risk or absolute burden as depicted by mortality rates. When comparing rankings across groups or over time, careful note should be made of the age distribution of the populations being compared. It is also important to note that rankings do not necessarily denote the causes of death of greatest public health importance.11

Deaths by Place of Residence – Mortality data analysis in this report are based on records for all California resident deaths occurring in the fifty states, the District of Columbia, US territories, and Canada; all other worldwide resident deaths are excluded. Deaths to non-California residents were excluded from analysis.

Age Groups – The following age groups were used to compute age-specific and age-adjusted rates: under 1 year, 1-4 years, 5-14 years, 15-24 years, 25-34 years, 35-44 years, 45-54 years, 55-64 years, 65-74 years, 75-84 years, and 85 and older.

Race/Ethnicity – Beginning in 2000, the federal race/ethnicity reporting guidelines changed to allow more than one race to be recorded on death certificates. California initiated use of the new guidelines on January 1, 2000, and collects up to three races per certificate. To be consistent with population data, current reports tabulate race of decedent using all races identified on the certificate.

To meet the U.S. Office of Management and Budget minimum standards for race and ethnicity data collection and reporting, and to be consistent with the population data obtained from the Department of Finance, this report presents Hispanic and the following non-Hispanic race/ethnic groups: American Indian, Asian, Black, Pacific Islander, White, and Two or More Races. Hispanic origin of decedents is determined first and includes decedents of any race group or groups. Non-Hispanic decedents who were reported with two or more races are subsequently placed in the Two or More Races group. Single non-Hispanic race groups are defined as follows: the “American Indian” race group includes Aleut, American Indian, and Eskimo; the “Asian” race group includes Asian Indian, Asian (specified/unspecified), Cambodian, Chinese, Filipino, Hmong, Japanese, Korean, Laotian, Thai, and Vietnamese; the “Pacific Islander” race group includes Guamanian, Hawaiian, Samoan, and Other Pacific Islander; the “White” race group includes White, Other (specified), Not Stated, and Unknown.

Caution should be exercised in the interpretation of mortality data by race/ethnicity. Misclassification of race/ethnicity on death certificates may contribute to underreporting of deaths in American Indians, Asians, Hispanics, and Pacific Islanders.14 This could contribute to artificially low rates for these groups and the Two or More Races group. Race groups’ data that are not individually displayed on the tables or figures due to unreliable rates are collectively included the state data totals.

Trend Analysis – In this report, linear regression was performed to establish the presence of statistically significant trends over the period examined. The trends identified in the report as statistically significant are those for which an F test yielded a p-value less than or equal to 0.05 and had R-square values greater than 0.50 unless otherwise specified. Trend analyses were not performed in cases where rates for one or more years examined were unreliable.

References

1 State of California, Department of Public Health. Death Records, 2000-2010.

14 Rosenberg HM, et al. Quality of Death Rates by Race and Hispanic Origin: A Summary of Current Research, 1999. Vital and Health Statistics, Series 2, No. 128. National Center for Health Statistics. September 1999.